Medicare Rankings Favor Small, For-Profit Hospitals

In April, the Centers for Medicare and Medicaid Services (CMS) publicly revealed for the first time which hospitals achieved five stars and which had room for improvement based on patient experience per the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

Although these measures are not new, this year CMS assembled the star ratings from HCAHPS survey results and made them available on its consumer-facing website, in an effort to increase transparency.

The decision has not been met without controversy, particularly given the fact that just 251 hospitals out of more than 3,500 received five stars, and only two major teaching hospitals achieved the highest rating. Some professional groups, like the American Hospital Association (AHA), which issued a statement the day CMS released its ratings, believe the rankings risk “oversimplifying the complexity of quality care or misinterpreting what is important to a particular patient, especially since patients seek care for many different reasons.”

Others argue that there is a disconnect between what hospital leaders perceive as important drivers of patient experience and what patients really want. For instance, a 2013 Harvard Business Review article cites a 2012 survey in which C-suite leaders suggested new facilities, private rooms, on-demand food, bedside electronics, and more amenities were necessary to improve patient experience in the hospital.1

“I am surprised at how much controversy there is on this,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System and professor of health policy at the Harvard T.H. Chan School of Public Health. “Modestly good evidence suggests that hospitals that do well on patient experience scores are also the hospitals that have better patient outcomes on more hard measures, like mortality and evidence-based guidelines.”

“I think one of the most important things for a hospital to understand is [that] the methodology behind creating the star ratings and the way CMS structures the ratings does make it challenging to achieve the very highest score.” –Akin Demehin

Dr. Jha cites a February 2015 study, published in the Journal of Hospital Medicine, in which patients were moved from one clinical building to a newer one with more patient-centered features.2 The care team remained the same. The study concluded that patients were able to differentiate between satisfactory clinical care and their surroundings, and that clinical care had a greater impact on patient experience than any other factor.

“Was your pain controlled adequately? Were people responsive to your needs? Were you treated with dignity and respect?” Dr. Jha says. “I think it’s disrespectful to say patients can’t tell the difference between high thread-count bed sheets and being treated with disrespect.”

The HCAHPS survey, Dr. Jha notes, reflects important aspects of healthcare that only patients can report. It encompasses 11 measures that gauge, for example, how well patients felt nurses and physicians communicated with them. It also asks patients to provide an overall hospital rank on a 10-point scale (counting only those that receive a nine or 10), according to Kaiser Health News, and to rate the cleanliness and quietness of the rooms.

Hospitals must send surveys to a random sample of adult patients monthly, including those not on Medicare, within six weeks of discharge, and Inpatient Prospective Payment System hospitals should collect at least 300 surveys every four years, CMS says.

“I think one of the most important things for a hospital to understand is [that] the methodology behind creating the star ratings and the way CMS structures the ratings does make it challenging to achieve the very highest score,” says Akin Demehin, AHA senior associate director of policy.

While CMS applies adjustments to account for sampling methods and patient characteristics of hospitals, an analysis by Dr. Jha’s team showed significant disparities between the rankings of large, academic medical centers and those of small, for-profit hospitals, as well as a substantial difference between hospitals that provide for the greatest number of poor patients and those that serve the fewest.3

However, he writes on his blog, "An Ounce of Evidence," that survey methodology is not the problem and that he believes star ratings are a good idea. Although some hospitals might find themselves at score cut-offs—a one-point difference can translate to a full star change—it’s a “small price to pay to make data more accessible to patients,” he writes.

“There is pretty good evidence hospitals are paying attention, and one that gets a one or two-star rating may be motivated to be better,” Dr. Jha says.

“Every hospital is interested in this because it’s part of value-based purchasing,” says Trina Dorrah, MD, MPH, a hospitalist and director of quality at Baylor Scott & White Health in Round Rock, Texas.

Dr. Dorrah has authored two books focused on patient experience, and she suggests simple ways hospitals can work toward improving their HCAHPS scores, and potentially their star ratings, from having nurses round with physicians to installing communication-facilitating whiteboards in every room.

Her hospital also awards bonuses to the hospitalist group for achieving set goals. Some hospitalist programs around the country are also adding questions to their surveys to link individual providers to patient rankings, she said, though many also do it in aggregate, because linking patients to individual physicians can get “very messy.”

CMS advises caution in interpreting star rankings, acknowledging that they are not the only valuable measures of care quality. Despite the concern over the contextual value of the new rankings, Demehin says AHA supports use of the HCAHPS survey and the value of patient experience measures and believes they should be consulted in conjunction with other quality improvement efforts.

“When I’m really sick and I go to the hospital, I want to be treated with dignity and respect and I want my pain treated quickly, but I also want to survive and not develop an infection,” Dr. Jha says. “That’s obviously not in the star ratings.”